GW1-2022-04508_Well Construction - GW1_20220509

_ WELL CONSTRUCrrON RECORD For ImcnmlUscONLY:
This form can t+c owd for singk or mullipk%cells
1.Well Contractor information:
4.W'A7ERZON1ES•,
John Eisenman FROM TO DVsCRIP110N
%Vclt Cllnrniaot N..inx
ft. rt.
4439A
NC\VdlContrdctor Certification Ntunber 13 OUTeR R'L1NER01411`IkaDk
FROM I TO DIAMETER I THICKNESS MATERIAL
SAEDACCO Inc 0 it. 30 ft. 2" in. I SCH-40 PVC
(atiglaln rTank 16 TU INNER CASING'ORBING(%e6iknn2ltloscdaw1f'LIL
FROM I TO I DLAMFTER THICKNESS MATERIAL
2.Well Construction Permit q: ff. rt. �•
len till appli,-ableKellpennies fix.rounry.,Srhre.Yoriarwr.Iffer olerr.) fl. f4 in.
3.%Veil Itsc(chock well use): 17 SCRXEN ;
Water Supply Wall: FROM TO DIAMETYM SIOTSIFF. T111CKNI,I'$ MATF.RIAI:
OAgricultural i municipal/Public 30 11• 40 ft. 2" in. 010 SCH-40 PVC
OGeothcmfal(Heating/CooIIi118 Stipple) 011esidential Water Supph•(single) fl, ft. in.
OindustriaUColnnicrciA 011csidcntial%Nato Supph ']FROM FRrCROUT'
OM TO MATERLAt. J EMPI.ACT.MGNT IUETiIOD&AMOUNT
❑lrri ation 0 ft. 23 h. Portland Pour
Non-Water Supply Well:
rt. ft.
Wtilomiioring ORccovcr}'
injection Well:
DAquiferitccharge OGroundwalcrRcnlcdiation 19 SANDIC.'RAVEL PAC K'(it villkabW.
FROM I TO IMATi;Nlal, MMFI.A('/:NE�YMF"tf1O►f
❑Aquifer Storage and Rccovctp ❑Salinity Harrier 28 ft. 40 rt. SAND #2
❑AgniferTcst OstommaicrDminasc ft. ft
❑E.yl;rimcntal Technology OS%ftidcncc Cowml
,20 DRII.IANG'LOG attach sdditiunat shells if,necessan•
❑Geothennal(Closed Loop) ❑Tracer FROst TO mPSURIPt10Nfe6lor.hndnc%i,p,l1'nwkt%' W-bg.tec.)
DGeotitennal(I{eatintlCooline Return) DOther(cN lain under 021 Reuraris) 0 ft. 40 fr, clay
n. u.
4.Date Well(s)Completed: 4-19-22 Well ID#MW-3 11. r4
52,WO1 Lucathm: ft. ft. _•� ;..$ 1R
Wilson Carpet iL h. /Fad1h%)'O%cncrNemc Ficilih•1DR(if appli able) fl. fL �� ,y'Q uL�
20850 Catawba Ave., Cornelius, NC, 28031 ft. f1.
r r
Physical Address.Cin•,and Zip 21 REt►tARI(S' a: t,., a . »,,,, r.' ti *+ ;
Mecklenburg
bentonite seal from 23-29't:i
Conith Parcel I&WificnioDNo,fPN.)
Sh.Latitude and I.angitude in degmcs/minutes/scconds or decimal degrees: 22.Certification:
(ifuell twid,otte kdlottvl'is smilickno
'' 4/20/2022
Slgruulr.of E 9 ;�>,,r r ` Doc
6.Is(are)the well(.): .)Pernanent or OTemporan' � u �✓ �" �a3'!r '�t
•..is I,.e..l.onvtrnc•ted nt reverclanc*
idth 154 N AC 02C.' :`^ ft I:(h i'rLC,02(tO 11'ril Consirverinn Sfamlartls mulI&TY a
7.Is this a repair to an existing well: oVe. or ENo ropy of rhis rrran'l ha,t been pnvided run)h.-spell mcner.
if ihfs is a relxllr,fill eau ln(iwa w col omelinn infoomaritnt timl c.%pinia the own re of the
relmir muter 021 remarks serfim nr an die NMI of this form. 23.Site diagram or additional hell details:
You may use the back of this p ige to provide additional well site details or well
8.Number of wells constructed: 1 construction details: Yoti'mac'also anach additional pages if necewty.
For'"1111 e infection&nevi-warcr supp s bets ON1,1'with the same consiritefion.etra can
. tnitirone form. SUBMITTAL, INSTU-.TIONS
9.Total weil depth below land surface. 40 (ft.) 24a. For All Wells: Gubmil this form within 30 days of completion of well
For,twhiple wells liar rd1 depths ff difli•relu(exm„ple•3@2Nl'a.k126?/0!l'1 constmetion to the following;
10.Static water level below alp of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfxvoet level 0 above main,,use"<" 1617 Mail Serviec Center,Raleigh,SIC 27699-1617
11.Borehole diameter.6° (in) 2.1b.Ur I th'clion WcIIS ONLY: fit addition to sending the fonn to il►e address in
24a above. also subnfil a cop), of this foie) witiuu ?0 daps of completion of well
12.Wcll construction method: Air constmetion to the following:
(i c.angm m)ary.cable,dimct pusk etc_)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Vield(gem) Method of test: 24c.For Water Supply&injection Wells:
Also submit one cop)' of this form within 30 daps of completion of
13b.Disinfection type: __ _. Amount: w'oll constmetion to the cotint%� heahh defnnmcnt of the Catmh wllctc
consimctcd. I
Fann GW-1 Nonli Cafolism Dapannmit of EncirD11111cia and Natural Resources-Division of w'aictResotr&-m Revised August 2l)13